Provider Demographics
NPI:1922276252
Name:YOUTHCARE PEDIATRICS OF CENTRAL GEORGIA, PC
Entity Type:Organization
Organization Name:YOUTHCARE PEDIATRICS OF CENTRAL GEORGIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-923-3360
Mailing Address - Street 1:233 N HOUSTON RD
Mailing Address - Street 2:STE 140 H
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3074
Mailing Address - Country:US
Mailing Address - Phone:478-923-3360
Mailing Address - Fax:478-923-9977
Practice Address - Street 1:233 N HOUSTON RD
Practice Address - Street 2:SUITE 140-H
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3074
Practice Address - Country:US
Practice Address - Phone:478-923-3360
Practice Address - Fax:478-923-9977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000377836DMedicaid
C76901Medicare UPIN